Endoscopic anti-reflux therapies like anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation have shown efficacy for gastroesophageal reflux disease (GERD) in systematic reviews and meta-analyses. Anti-reflux mucoplasty (ARM-P), a refinement of ARMS, incorporates immediate closure of the resection site to reduce complications. Recently, anti-reflux mucosal valvuloplasty (ARMV), which employs endoscopic submucosal dissection to create a mucosal valve, was introduced but retains ARMS's limitations, requiring extensive incisions (three-quarters to four-fifths circumference). To address these challenges, we developed anti-reflux mucoplasty with valve (ARM-P/V), integrating ARMV's valvuloplasty with ARM-P's closure technique to improve safety and reduce complications. This pilot study evaluates the safety, feasibility, and efficacy of ARM-P/V.

This retrospective study reviewed data from patients undergoing ARM-P/V for proton pump inhibitor (PPI)-refractory or PPI-dependent GERD at Showa University Koto Toyosu Hospital, Tokyo, from April to August 2024. Symptom severity and quality of life were assessed using validated questionnaires (GERD-Health Related Quality of Life Questionnaire [GERD-HRQL], GERD Questionnaire [GerdQ], and Frequency Scale for the Symptoms of GERD [FSSG]), comparing pre- and post-treatment scores. PPI discontinuation rates were also analyzed.

Eighteen patients (mean age 55.4 years) underwent ARM-P/V. Within 3 months, 72.2% (13/18) reduced or discontinued PPI use. GERD-HRQL scores improved from 20.3 to 10.9 (p = 0.004), GerdQ from 10.4 to 6.9 (p < 0.001), and FSSG from 24.0 to 13.2 (p < 0.001). No severe complications (Clavien-Dindo Grade ≥3), delayed bleeding or dysphagia requiring balloon dilation were reported.

ARM-P/V demonstrates safety, technical feasibility, and short-term efficacy in GERD treatment. As a refinement of ARMV, it offers a promising alternative to current techniques.

laparoscopic Nissen fundoplication (LNF) is the gold standard of antireflux surgery. Up to 30 % of patients experience symptoms after surgery, with insufficient information available. The main objective was to evaluate epidemiological, clinical, and functional factors associated with symptoms after LNF.

a retrospective case-control study was performed of 79 operated patients (2015-2024). The relationship between epidemiological data, functional tests, and imaging study results with the occurrence of symptoms after LNF was assessed.

twenty-four asymptomatic and 55 symptomatic patients were included. Functional and imaging tests were normal in the majority of asymptomatic patients. integrated relaxation pressure over 4 seconds (IRP-4s) (95th percentile) in asymptomatic patients was 20.4 mmHg. Female gender (OR 4, 95 % CI: 1.1-14), preoperative dysphagia (OR 8.2, 95 % CI: 1.4-47.6), and IRP-4s (OR 1.2, 95 % CI: 1-1.3) were independent factors for postoperative dysphagia. Type III esophagogastric junction morphology on high-resolution manometry (OR 6.1, 95 % CI: 2.1-18.1) was independently associated with gastroesophageal reflux disease (GERD) symptoms. Acid exposure time (AET) showed a trend toward being an independent factor but did not reach statistical significance (OR 1.1, 95 % CI: 1-1.3). Hiatal hernia in the esophagogram was associated with reintervention (OR 5.5, 95 % CI: 1.6-19.1).

asymptomatic patients mostly have normal functional tests after LNF, although IRP-4s normal value (95th percentile) is higher than proposed in the Chicago classification. Preoperative dysphagia and female gender are independent factors for postoperative dysphagia, which should be considered in the preoperative assessment. Functional and imaging tests are essential in evaluating patients with postoperative symptoms. Dysphagia is associated with higher IRP while GERD symptoms are related to type III esophagogastric junction (EGJ) on high resolution manometry (HRM). Similarly, a hiatal hernia on the esophagogram is associated with reintervention.

Mean nocturnal baseline impedance (MNBI) is a novel metric for multichannel ambulatory impedance and pH (MI-pH) monitoring used to diagnose gastroesophageal reflux disease (GERD); however, its thresholds vary among different geographic areas and measuring systems. This study analyzed MI-pH data from Vietnamese patients to assess the diagnostic utility of novel MNBI thresholds in identifying GERD.

This retrospective study included 133 patients suspected of having GERD who underwent upper gastrointestinal endoscopy, esophageal high-resolution manometry (HRM) and 24-hour MI-pH monitoring (Laborie). The subjects were divided into 3 groups based on the acid exposure time (AET) index (abnormal, inconclusive and normal AET). The mean MNBI and the prevalence of abnormal MNBI values were compared within groups, and the diagnostic accuracy of this index for diagnosing GERD was evaluated via receiver operating characteristic (ROC) curves and their area under the curve (AUC).

MNBI was significantly lower in patients with abnormal AET. The prevalence of MNBI < 2292 Ohms and MNBI < 1500 Ohms were greater in patients with abnormal AET (91.2% and 79.4%, respectively). The percentage of MNBI > 2500 Ohms was 44.4% in patients with normal AET but only 2.9% in patients with abnormal AET. MNBI had the highest AUC in discriminating abnormal AET (0.90, p < 0.001) in comparison with other metrics on MI-pH monitoring. The new cutoff value of 1500 Ohms had lower sensitivity but higher specificity than the previous threshold of 2292 Ohms. A multivariable regression analysis revealed that an MNBI < 1500 Ohms and total number of reflux events > 80/day were significantly associated with abnormal AET (> 6%).

Among Vietnamese patients with suspected GERD, the new MNBI cutoff of > 1500 Ohms had high sensitivity and specificity in diagnosing GERD, while the cutoff of 2500 Ohms could rule out this disease.

Dysphagia and reflux are frequently experienced by individuals with hiatus hernia (HH), but the underlying mechanisms are not fully defined in radiological or manometric studies. This study explores the impact of HH on propulsive esophageal peristalsis and investigates the biomechanical underpinnings of HH-concurrent-related dysphagia in affected individuals.

High-resolution manometry with impedance (HRM-I) studies compared the biomechanics of 195 gastroesophageal reflux disease (GERD) patients (excluding large HH and motility disorders) and 20 normal healthy volunteers. Assessments included dysphagia severity, esophageal pH monitoring, and HRM-I with 5-mL liquid and viscous swallows. Bolus distension pressures during bolus transport and esophageal emptying parameters were assessed in conjunction with standard pressure topography metrics. Data grouped by EGJ morphology type were analyzed by a mixed-effects statistical model.

Patients with unequivocal HH exhibited altered bolus transport through the mid-distal esophageal body, indicated by increased intrabolus distension pressure during bolus transport (p < 0.01 for liquid and viscous swallows) and shorter bolus flow time through the EGJ (p ≤ 0.005 for liquid and viscous swallows). Increased HH size during swallows also correlated with increased intrabolus distension pressure (liquid r 0.243, p < 0.001) and shorter EGJ flow time (liquid r - 0.191, p < 0.005). Patients with confirmed GERD without HH showed a different pattern of altered bolus transport in the more proximal esophagus.

In the presence of a HH, esophageal biomechanics are altered, with elevated bolus distension pressure revealing resistance to bolus transport occurring in the mid-lower esophageal body for liquid and viscous boluses, contributing to dysphagia symptoms.

Mycobacterium avium complex (MAC) pulmonary infection was previously associated with gastroesophageal reflux disease (GERD), although the effects of GERD on MAC outcomes remains unclear. The goal of this study was to assess the prevalence of GERD in patients with MAC pulmonary infection and its association with clinical outcomes.

This was a retrospective study of adult patients with confirmed MAC pulmonary infection who underwent ambulatory pH monitoring. Pathologic acid reflux was defined as a total distal acid exposure time ≥6 %. Adjunctive esophageal tests including esophagogastroduodenoscopy, barium esophagram, and high-resolution manometry were assessed. The primary outcomes were pulmonary function testing and treatment of MAC pulmonary infection.

Of 132 included patients, 35 (26.5 %) had an acid exposure time ≥6 %. There were no differences between patients with and without pathologic acid reflux by AET and pulmonary function tests including FEV1 absolute (1.79 vs. 1.83 L, p = 0.68), FEV1 % predicted (78.6 vs. 78.0 %, p = 0.94), FEV1/FVC % predicted (71.1 vs. 68.0 %, p = 0.38), or DLCO % predicted (66.0 vs. 79.0 %, p = 0.097). Additionally, there were no differences in MAC pulmonary infection outcomes including antimicrobial treatment, duration, or lobectomy. Findings on adjunctive esophageal testing did not associate with outcomes by pulmonary function tests or treatment of MAC pulmonary infection.

The prevalence of GERD in patients with MAC pulmonary infection based on ambulatory pH monitoring was 26.5 %. MAC pulmonary infection with GERD was not associated with worse outcomes and further study is needed to assess the impacts of GERD on MAC pulmonary infection.

This comprehensive narrative review thoroughly explores the treatment landscape for achalasia, a rare esophageal motility disorder. Beginning with an introduction outlining the anatomical and clinical aspects of achalasia, the review delves into its historical perspective, tracing the evolution of treatment options from early nonsurgical methods to advanced surgical techniques such as Heller's myotomy and peroral endoscopic myotomy (POEM). Technical perspectives on surgical interventions, including key steps, clinical practice guidelines, and modifications to POEM techniques, are extensively discussed. A comparative analysis between POEM and Heller's myotomy elucidates their indications, contraindications, efficacy, outcomes, and interventions for persistent symptoms or complications. Furthermore, the review explores the adverse events associated with both procedures, highlighting their safety profiles and management strategies. Finally, from a financial perspective, considerations such as operative time, hospital stay length, readmission rates, and quality-adjusted life years are examined, emphasizing the implications for patient decision-making. This review underscores the importance of a multidimensional approach to understanding and managing achalasia, advocating for further research to enhance treatment efficacy and reduce adverse effects.

We report the case of a 19-year-old White male diagnosed with familial adenomatous polyposis (FAP), Gardner's syndrome (GS) phenotype, status post total colectomy, who developed progressive dysphagia and weight loss. He was diagnosed with achalasia based on imaging and esophageal manometry. The patient underwent a Heller myotomy with the resolution of symptoms. To date, no previous literature has reported on concurrent FAP or GS and achalasia. Although FAP and achalasia are both rare conditions with no previously known concurrent occurrence, association, or described syndrome, it is important to be vigilant of this new case report finding. One must also consider the increased risk of malignancy in patients with achalasia in addition to the significant risk of malignancy in patients with FAP/GS.

The distribution of body weight in patients with achalasia and after peroral endoscopic myotomy (POEM) has not been investigated. The role of body weight assessment after treatment remains unclear.

Using the multicenter achalasia cohort, the frequency of underweight (body mass index [BMI] < 18.5 kg/m2) and overweight (BMI ≥ 25.0 kg/m2) and their associated clinical characteristics were analyzed. After POEM, risk factors for insufficient- (underweight persistently) and excessive- (responded to overweight) weight gainers were investigated. The correlation between BMI-increase rate and severity of esophageal symptoms post-POEM was evaluated.

Among 3,410 patients, 23.0% and 15.7% were underweight and overweight, respectively. Factors associated with underweight were higher age, female sex, severe symptoms, high lower esophageal sphincter (LES) pressure, and non-dilated esophagus (all p < 0.01). Longitudinal analyses revealed that weight gain post-POEM was achieved after a long duration (≥ 12 months; p < 0.01). In 528 patients post-POEM, the frequency of underweight reduced to 8.3% (p < 0.01). Risk factors for insufficient-weight gain (36.1% of underweight patients) included low BMI (p < 0.01) and high LES pressure (p = 0.03) and conversely for excessive-weight gain. Machine learning models based on patient characteristics successfully predicted insufficient- and excessive-weight gainers with an area under the curve value of 0.74 and 0.75, respectively. Esophageal symptoms post-POEM did not correlate with BMI increase.

Underweight is not solely a condition of advanced achalasia. After POEM, insufficient- or excessive-weight gainers are not rare and can be predicted preoperatively. Body weight change is an independent nutrition parameter rather than a part of the assessment of residual esophageal symptoms.

The number of studies exploring esophageal motility disorders using high-resolution manometry (HRM) in patients with esophageal diverticula (ED) is limited. The goal of this study was to describe motility disorders using HRM in patients with ED and assess the added value of provocative testing in these patients.

Patients with ED who underwent HRM between 2010 and 2022 were retrospectively included. HRM findings were compared based on single water swallows (SWS), and provocative testing with solid food swallows in the upright seated position, using both ManoView and Medical Measurement Systems software. We also calculated median pressure slopes during the compartmentalization phase.

Sixteen of the 39 included patients had mid-ED and 23 had lower ED. Twenty (51.3%) patients had motility disorders based on SWS, including 7 (18%) with achalasia and 3 (7.7%) with esophagogastric junction obstruction. No significant differences in esophageal motility disorders were observed in relation to the location of the ED. Solid food swallows were performed in 29 (74%) patients leading to a change in the HRM diagnosis in 7 (24.1%), all of whom showed elevated IRP. Median pressure slopes during the compartmentalization phase (n = 30) were elevated in patients both with and without motility disorders.

Half of the patients with mid- or lower ED had motility disorders on HRM. Adding solid food swallows during HRM in patients with ED improves the manometric diagnosis. Results suggest abnormal distensibility in these patients, indicated by elevated pressure slope, regardless of the presence of associated motility disorders.

Ineffective esophageal motility is the most frequent disorder of esophageal peristalsis. Symptoms may include dysphagia, chest pain, and heartburn. Our aims are to evaluate the long-term prognosis and determine if provocative tests during high-resolution esophageal manometry could predict the prognosis.

We retrospectively assessed high resolution manometries performed between 2015-2018 in adult patients. Symptoms were evaluated at baseline and at follow-up (median 39 months later) using the impact dysphagia questionnaire (IDQ-10), where a score ≥ 7 defined dysphagia, the gastroesophageal reflux disease questionnaire (GerdQ), where a score ≥ 9 defined symptoms of reflux disease and if the subject had chest pain ≥ once a week. Chicago classifications version 3.0 and 4.0 were used. The contractile reserve was assessed by identifying whether esophageal peristalsis normalized or not on solid bolus swallows and a rapid drink challenge was included.

Nine hundred and eighty investigations performed during the study period; 114 patients (11.6%) were identified with ineffective esophageal motility. The final study cohort consisted of 33 patients of which 42% had dysphagia at follow-up and 25% had chest pain at least once a week, 46% had reflux symptoms. Patients who normalized motility on solid bolus swallows reported less dysphagia upon follow-up (P = 0.012), nevertheless reported similar proportions of chest pain (P = 0.632), and reflux (P = 0.514). There were no associations between having dysphagia, chest pain, or reflux at follow-up, and abnormal findings on the rapid drink challenge (P > 0.05 for all).

Patients with ineffective esophageal motility continue to experience long-term esophageal symptoms at follow-up. Provocative tests seem to have the potential to partly predict the long-term prognosis of dysphagia.

Achalasia is a movement disorder of the esophagus that continues with chest pain, dysphagia, weight loss, regurgitation of undigested foods, recurrent aspiration and night cough.

Weight loss, presence of dysphagia, presence of retrosternal pain and regurgitation were recorded before POEM treatment and preoperative Eckardt Score was calculated and recorded. Patients were recorded at the 6th month after POEM treatment recording weight loss, dysphagia presence, retrosternal pain and regurgitation presence and calculating postoperative Eckardt score.

The change between the postoperative and preoperative values of the patients was calculated as ∆ value. As a result of the examination, no significant difference was found between the values ∆weight loss, ∆dysphagia, ∆retrosternal pain, ∆regurgitation and ∆Eckardt score and gender variable (respectively, p=0.112; p=0.412; p=0.619; p=0.171; p=0.092). Postoperative weight loss, dysphagia, retrosternal pain, regurgitation and Eckardt score values were found to be lower than preoperative values. (respectively, p<0.001;p<0.001; p<0.001; p<0.001; p<0.001).

Peroral endoscopic myotomy treatment is an effective treatment method with its being more reliable, lower complication risk, being less invasive and with postprocedural and clinical results.

In patients with non-cardiac chest pain (NCCP) and non-obstructive dysphagia (NOD), standard esophageal high resolution manometry (HRM) with water swallows and/or solid meals may miss intermittent dysmotility. To what extent prolonged 24 h-measurements may increase the diagnostic sensitivity is currently unclear.

75 patients (47 female, 58 ± 16 years) with NCCP and/or NOD underwent standard HRM (single water swallows plus rice meal) and ambulatory 24-h-HRM with impedance. Results were analyzed according to Chicago Classification v3.0 for water-swallow-HRM; adapted criteria were used for rice-meal and 24-h-HRM. Patients were followed by chart review.

Contractility parameters obtained by different HRM procedures always correlated (R > 0.27, p < 0.05). During 24 h-measurements, all parameters showed circadian variability (p < 0.001). In comparison with water-swallow-HRM, rice-meal-HRM markedly increased the proportion of patients diagnosed with achalasia III, esophagogastric outlet obstruction with spastic features, distal esophageal spasm, or hypercontractility (10.7% vs. 21.3%, p = 0.039). The diagnostic gain regarding spastic and/or hypercontractile disorders was further increased by 24-h-HRM (61.3% of patients, p < 0.001). In 11 out of 21 patients with normal results in both water-swallow- and rice-meal-HRM (15% of total cohort), 24-h-HRM detected a major motor disorder. Results of 24-h-HRM altered treatment recommendations in 41 patients (54%).

24-h-HRM revealed spastic and/or hypercontractile esophageal motor disorders in about 60% of patients with NCCP/NOD and markedly improved diagnostic yield compared with standard HRM, probably partly due to the observed circadian variability of esophageal motility. 24-h-HRM findings frequently altered treatment recommendations, but the ultimate clinical consequences of the increased diagnostic yield have to be examined further.

This retrospective study aimed to compare treatment outcomes and postoperative courses, including the incidence of esophageal cancer (EC), according to disease types, in 450 achalasia patients who underwent peroral endoscopic myotomy (POEM).

Data from consecutive POEM procedures performed from September 2011 to January 2023 at a single institution were reviewed. Achalasia was classified into straight (St), sigmoid (S1), and advanced sigmoid (S2) types using esophagography findings. Regarding efficacy, POEM was considered successful if the Eckardt score was ≤3. A statistical examination of the incidence and trend of EC occurrence across the disease type of achalasia was conducted using propensity score matching.

Of the 450 patients, 349 were diagnosed with St, 80 with S1, and 21 with S2. POEM efficacy was 97.9% at 1 year and 94.2% at 2 years postprocedure, with no statistical difference between disease types. Using propensity score matching, the incidence of EC in each disease type was as follows: St, 1% (1/98); S1, 2.5% (2/77); S2, 10% (2/18). While no statistical significance was observed between St (1.0%: 1/98) and all sigmoid types (4.0%, 4/95; P = 0.3686). However, a trend test revealed a tendency for EC to occur more frequently in the order of S2, S1, and St type with a statistically significant difference (P = 0.0413).

Outcomes of POEM are favorable for all disease types. After POEM, it is important not only to monitor the improvement of achalasia symptoms but also to pay attention to the occurrence of EC, especially in patients with sigmoid-type achalasia.

Achalasia is an esophageal motility disorder of unknown etiology. However, no studies have determined the populations in which sleep problems occur and whether they are improved by peroral endoscopic myotomy (POEM). We investigated the rate of sleep problems assessed by GERD-Q (AGQ) in achalasia patients, evaluated whether POEM improves these issues, and identified factors associated with sleep improvement after POEM.

We retrospectively analyzed the data of patients who were diagnosed with achalasia and who underwent POEM at a single institution between March 2016 and December 2020. We examined the Eckardt symptom score and the GERD-Q before and 3 months after POEM to assess the presence of sleep problems (AGQ) and other symptoms. The univariate logistic regression analysis was performed to identify factors associated with sleep problem (AGQ) improvement after POEM.

A total of 177 patients were included. The average age was 52.6 ± 17.2 years. Preoperatively, dysphagia (172 [97.2%]), regurgitation (123 [69.5%]), sleep problems (AGQ; 110 [62.1%]), chest pain (102 [57.6%]), and weight loss (83 [46.9%]) were observed. Before POEM, 62.1% of patients experienced sleep problems (AGQ) compared with 9.6% after POEM (p < 0.0001). Postoperative dysphagia and regurgitation were significant factors determining whether patients continued to experience sleep problems (AGQ) after POEM.

Sleep problems (AGQ) were the third most common symptom in > 60% of patients with achalasia. Improving dysphagia and regurgitation using the POEM procedure improved sleep problems (AGQ).

High-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. While studies have previously reported on HRM findings in patients with dysphagia and/or chest pain, we sought to compare the yield and findings of HRM based on different indications for motility testing.

A retrospective study was performed including all successful HRM studies performed at two tertiary medical centers between 2018 and 2023. The indication was categorized as either: (1) dysphagia; (2) GERD evaluation; (3) non-cardiac chest pain; (4) epigastric pain; (5) regurgitation/vomiting; or (6) prior to esophageal surgery. Motility disorders were diagnosed as per the Chicago Classification, version 4.0.

A total of 768 patients were included (mean age 55.5 +/- 17.3; 56.2% female). The most common indications were dysphagia (368, 47.9%) and prior to reflux testing (267, 34.8%). Normal motility was found in 417 (54.3%) patients while a motility disorder was diagnosed in 351 (45.7%) subjects. A major motility disorder was found in 178 (23.2%) cases, with achalasia in 82 (10.7%) patients. HRM diagnoses significantly differed based on the indication for testing (p < 0.001), with major motility disorders and achalasia being most commonly diagnosed when performed for dysphagia and recurrent regurgitation/vomiting. The indication affected the likelihood of having any motility disorder (p = 0.010), a major motility disorder (p < 0.001), a disorder of EGJ Outflow (p < 0.001), and achalasia (p < 0.001).

The indication for HRM testing affects the likelihood of having a motility disorder including achalasia. The highest yield is in patients being evaluated for dysphagia and regurgitation/vomiting.

EG-840TP is a novel small-caliber therapeutic endoscope with a large working channel. We aimed to evaluate the treatment outcomes of peroral endoscopic myotomy using EG-840TP compared to those using a conventional therapeutic endoscope (GIF-H290T).

Patients who underwent peroral endoscopic myotomy for achalasia and non-achalasia esophageal motility disorders were enrolled between March 2021 and March 2023. Procedure times and other treatment outcomes were compared between patients treated with EG-840TP and GIF-H290T using propensity score matching analysis. In the subgroup analysis, patients were divided into subsets based on myotomy length, morphology, esophageal dilation, and operator skill, and the procedure time was compared between the matched groups.

A total of 154 patients were enrolled in this study, and 39 patients treated using each type of scope were matched. The EG-840TP group tended to have a shorter procedure time than the GIF-H290T group. There were no significant differences between the groups in terms of short-term clinical success or perioperative adverse events. In the subgroup analysis, the procedure time of the EG-840TP group was significantly shorter than that of the GIF-H290T group when patients had a straight esophagus (44 min vs. 54 min, p = 0.0015) and the operator was a non-expert (49 min vs. 64 min, p = 0.031).

POEM using EG-840TP showed procedure time, clinical success, and adverse events equivalent to those of a conventional therapeutic endoscope. However, EG-840TP potentially contributed to a shorter procedure time in patients with a straight esophagus or in non-expert operators than GIF-H290T.

Laparoscopic Heller myotomy is a primary treatment for achalasia, addressing impaired esophageal motility. Fundoplication is typically added to prevent postoperative reflux. This study compares outcomes of limited hiatal dissection without antireflux system in laparoscopic Heller myotomy to Dor fundoplication.

A retrospective analysis was conducted on 45 patients treated at visceral surgery department (2008-2022). Of these, 29 patients underwent limited hiatal dissection, and 16 underwent Dor fundoplication. A liquid diet was followed on day one, with discharge on day two, and a semi-liquid diet for three weeks. Outcomes included dysphagia resolution, postoperative Eckardt scores <3, and postoperative reflux incidence. The study compared operative and postoperative data between the two groups.

The limited hiatal dissection group had a slightly younger mean age (46.97 years) compared to the Dor fundoplication group (51.75 years). The limited hiatal dissection group had a higher proportion of men (58.6 %) while the Dor group had more women (56.3 %). Dysphagia (100 %) and weight loss (68.9 %) were prevalent symptoms. Perioperative complications and hospital stay duration were similar. Operative time was significantly shorter in the limited hiatal dissection group (96.7 vs. 118.3 min, p = 0.004). Both groups showed similar (OR = 0.519, CI = 0.066-4.083) and significant improvement in dysphagia (91.3 % vs. 87.5 %, p < 0.001) with comparable postoperative gastroesophageal disease (20.7 % vs. 25 %, p = 0.726 OR = 1.278, 95 % CI: 0.301-5.420).

Limited hiatal dissection provides comparable symptom relief and reflux prevention, offering a viable alternative to routine antireflux in achalasia treatment.

There is scarce information on the state of general gastrointestinal (GI) fellow knowledge of esophageal motility and the interpretation skills of esophageal high-resolution manometry (HRM).

This study aimed to assess GI fellow knowledge of esophageal motility and manometry interpretation.

A 6-month educational program consisting of eight didactic sessions in the form of a weekly educational email, three didactic conferences, and handouts pertaining to the Chicago Classification (v3.0) of esophageal HRM was conducted. Both pre- and post-intervention surveys were collected using SurveyMonkey®. Five questions assessed fellows' knowledge of esophageal motility and manometry, and two questions examined their self-assessment of knowledge and confidence in managing esophageal motility disorders (EMDs). Descriptive statistics and Student's t test were used for the analysis.

Ten GI fellows (four first-year, five second-year, and one third-year) from a single academic institution participated in the intervention. Fellows showed a trend for better knowledge of the clinical aspects of esophageal motility over HRM interpretation (P value 0.09). On a scale of 1-5, with 5 being the highest, fellows' self-assessment of esophageal motility knowledge pre-intervention averaged 1.8 (SD 0.78) and post-intervention 2.9 (SD 0.99); P value 0.007. Fellows' confidence in managing EMDs pre-intervention averaged 1.7 (SD 0.66) and post-intervention 2.8 (SD 0.91); P value 0.04. Subgroup analyses, including fellows' self-assessment of knowledge, and fellows' confidence in managing EMDs, maintained statistically significance for level of training.

GI fellow knowledge of esophageal motility and manometry interpretation, as well as confidence in managing EMDs, improved significantly after a 6-month formal educational program.

Most patients who were included in previous studies on achalasia had increased lower esophageal sphincter (LES) pressure. Peroral endoscopic myotomy (POEM) has been confirmed to be effective at relieving the clinical symptoms of achalasia associated with increased LES pressure.

To identify the safety and efficacy of POEM for patients with normal LES integrated relaxation pressure (LES-IRP).

The clinical data of patients who underwent POEM successfully in The First Medical Center of Chinese PLA General Hospital were retrospectively analyzed. A total of 481 patients who underwent preoperative high-resolution manometry (HRM) at our hospital were ultimately included in this research. According to the HRM results, the patients were divided into two groups: 71 patients were included in the normal LES-IRP group (LES-IRP < 15 mmHg) and 410 patients were included in the increased LES-IRP group (LES-IRP ≥ 15 mmHg). Clinical characteristics, procedure-related parameters, adverse events, and outcomes were compared between the two groups to evaluate the safety and efficacy of POEM for patients with normal LES-IRP.

Among the 481 patients included in our study, 209 were males and 272 were females, with a mean age of 44.2 years. All patients underwent POEM without severe adverse events. The median pre-treatment Eckardt scores of the normal LES-IRP and increased LES-IRP groups were 7.0 and 7.0 (P = 0.132), respectively, decreasing to 1.0 and 1.0 post-treatment (P = 0.572). The clinical success rate of the normal LES-IRP group was 87.3% (62/71), and that of the increased LES-IRP group was 91.2% (374/410) (P = 0.298). Reflux symptoms were measured by the GerdQ questionnaire, and the percentages of patients with GerdQ scores ≥ 9 in the normal LES-IRP and increased LES-IRP groups were 8.5% and 10.7%, respectively (P = 0.711). After matching, the rates of clinical success and the rates of GerdQ score ≥ 9 were not significantly different between the two groups.

Our results suggest that POEM is safe and effective for achalasia and patients with normal LES-IRP. In addition, in patients with normal LES-IRP, compared with those with increased LES-IRP, POEM was not associated with a greater incidence of reflux symptoms.

Esophageal motility disorders (EMDs) encompass a range of functional abnormalities, including achalasia, ineffective esophageal motility (IEM), esophagogastric junction outflow obstruction (EGJOO), and distal esophageal spasm (DES). Diagnostic modalities like high-resolution esophageal manometry (HREM), Functional Lumen Imaging Probe (FLIP), and impedance analysis are invaluable but often limited by interpretive variability and the need for expert analysis. Artificial intelligence (AI) has emerged as a transformative tool in addressing these challenges. This manuscript explores the integration of AI in EMD diagnostics, showcasing its ability to enhance diagnostic accuracy, optimize workflows, and standardize interpretation across centers. Advanced algorithms, including convolutional neural networks (CNNs) and machine learning (ML) models, achieve high accuracy in automating classifications, subtyping disorders like achalasia, and improving diagnostic consistency. Furthermore, AI's predictive capabilities extend to treatment outcome modeling, enabling personalized care strategies and longitudinal tracking. AI also offers significant potential in medical education by reducing learning curves and standardizing esophageal motility interpretation training. These advancements collectively emphasize the role of AI in revolutionizing EMD diagnosis, treatment, and training, promising improved patient outcomes and broader clinical utility.

Patients with esophageal motility disorders (EMDs) sometimes develop bacterial pneumonia (BP). However, factors associated with BP in patients with EMDs and whether peroral endoscopic myotomy (POEM) reduces BP development are unclear. Therefore, this study aimed to identify factors associated with BP development and evaluate the preventive potential of POEM in patients with EMDs.

This study included 623 patients diagnosed with EMDs at our institution between April 2015 and March 2023. Factors associated with BP were analyzed by comparing characteristics between patients who developed BP within 1 year before diagnosis using multivariable analysis. The potential of POEM to prevent BP development was assessed using Cox regression analysis, considering treatment status as a time-varying covariate.

Of the 623 patients, 31 (5.0%) developed BP within 1 year before diagnosis. Older age (odds ratio [OR] = 1.29, 95% confidence interval [CI] 1.04-1.59, p = 0.019; 10-year increments), lower body mass index (OR = 0.87, 95% CI 0.78-0.98, p = 0.026), and manometric diagnosis of spastic esophageal disorders (OR = 2.97, 95% CI 1.24-7.16, p = 0.015) were significantly associated with BP. Treatment status of POEM was proved to be a significant factor for developing BP using Cox regression analysis (hazard ratio = 0.17, 95% CI 0.039-0.75, p = 0.019).

Risk factors associated with BP in patients with EMDs were older age, lower body mass index, and manometric diagnosis of spastic esophageal disorders. POEM could decrease spasm-related bolus reflux, improve patients' nutritional status through resolution of transit disturbance, and reduce respiratory complications, suggesting that POEM could help prevent BP development.

Background/Objectives: Gastroesophageal reflux disease (GERD) is associated with extraesophageal syndromes that require an objective assessment of abnormal acid exposure to establish the diagnosis. The COuGH RefluX score has been proposed as a diagnostic tool for GERD in patients with chronic laryngopharyngeal symptoms. The aim of the study was to evaluate the diagnostic performance of the COuGH RefluX score in the Mexican population. Methods: A cross-sectional study was conducted in patients with chronic laryngopharyngeal symptoms. Patients with cough, globus, sore throat, dysphonia, and/or throat clearing of ≥8 weeks duration, 24 h pH-impedance monitoring (pH-IM), and without objective evidence of GERD (defined as acid exposure time >6%) were included in the study. The COuGH RefluX score tool was applied and stratified as low probability with ≤2.5 points, intermediate probability with 3.0 to 4.5 points, and high probability with ≥5.0 points. The kappa test assessed the concordance between both tests; the area under the curve (AUR), sensitivity (S), specificity (E), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each result. Results: 164 patients were included; the prevalence of GERD by pH-IM was 32% vs. 40.3% by COuGH RefluX score, the agreement was weak (κ = 0.34; p < 0.001), but the AUR was good (0.720 ± 0.17; p < 0.001). A score ≤ 2.5 had S = 49%, E = 88%, PPV = 89%, and NPV = 42% to rule out proven GERD, while a score ≥ 5 had S = 65%, E = 71%, PPV = 52%, and NPV = 82% for proven GERD. Conclusions: The COuGH RefluX score has low sensitivity but adequate specificity for GERD diagnosis in Mexican patients with chronic laryngopharyngeal symptoms.

Peroral plication of the esophagus (POPE) can reduce sump size and improve symptoms in end-stage achalasia. However, its long-term efficacy and safety are unknown.

Patients with end-stage achalasia who underwent POPE at our institution (2016-2024) were identified. Data were abstracted for patient demographics, procedural details, and clinical and radiographic outcomes.

Twelve patients underwent POPE. The technical success rate was 100%, with mean procedural time of 57 minutes and without adverse events. Symptomatic improvement occurred in 75% of patients (mean follow-up of 15 months), while 86% had radiographic improvement in sump size. Repeat POPE in 6 (50%) patients a mean of 2.6 years after index POPE and a third POPE in four (33%) patients a mean of 3.1 years later was performed, with similar technical success rates and outcomes to the index POPE.

POPE is a safe and repeatable long-term therapeutic option in end-stage achalasia.

High-resolution manometry (HRM) is a gold standard for diagnosing achalasia and identification of its subtypes, but data regarding its correlation with clinical, endoscopic, and radiological features in low-resource settings like Pakistan are limited. This study aims to identify and compare manometric parameters with other diagnostic parameters among achalasia subtypes in Pakistani population.

A retrospective analysis of clinical, endoscopic, and radiological features of 381 patients who underwent HRM at Center for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, Pakistan, from December 2015 to February 2024 was performed. Based on the HRM criterion, 213 patients were identified and categorized into subtypes: 132 cases for type I and 64 and 17 for type II and III, respectively.

Patient demographics were similar across subtypes except for sex (male-dominant in types I and II, female-dominant in type III). Symptom duration was longest in type III (8 years vs. 4.1 years). Almost all patients had dysphagia; 83% reported regurgitation/weight loss, 71% chest pain, and 64% vomiting. The endoscopy results were normal in 40% of patients, and barium swallow was inconclusive in just 13% of achalasia patients. Type III exhibited the highest EGJ relaxation pressure and lowest LES pressure. Notably, all subtypes displayed elevated IRP, with type I showing highest value.

This study identified type I achalasia as the most prevalent subtype. While barium swallow and endoscopy showed limited diagnostic accuracy, HRM confirmed subtypes in all patients. Despite challenges with GERD-like symptoms and inconclusive findings, further research is warranted to investigate specific clinical features of each subtype, potentially attributing to personalized treatment strategies.

Early identification of patients needing hospital-specific interventional care (HIC) following endoscopic treatment is valuable for optimizing postoperative hospital stays. We aimed to develop and validate a risk-scoring system for predicting HIC in patients who underwent peroral endoscopic myotomy (POEM).

This study included patients with esophageal motility disorders who underwent POEM at our hospital between April 2015 and March 2023. HIC was defined as any of the following situations: fasting for gastrointestinal rest to manage adverse events (AEs); intravenous administration of medications such as antibiotics and blood transfusion; endoscopic, radiologic, and surgical interventions; intensive care unit management; or other life-threatening events. A risk-scoring system for predicting HIC after postoperative day (POD) 1 was developed using multivariable logistic regression and was internally validated using bootstrapping and decision curve analysis.

Of the 589 patients, 50 (8.5%) experienced HIC after POD1. Risk scores were assigned for four factors as follows: age (0 points for <70 years, 1 point for 70-79 years, 2 points for ≥80 years), preoperative prognostic nutritional index (0 points for >45, 1 point for 40-45, 4 points for <40), postoperative surgical site AEs on second-look endoscopy (7 points), and postoperative pneumonia on chest radiography (6 points). The discriminative ability (concordance statistics, 0.85; 95% confidence interval, 0.78-0.91) and calibration (slope 1.00; 0.74-1.28) were satisfactory. The decision curve analysis demonstrated its clinical usefulness.

This risk-scoring system can predict the HIC after POD1 and provide useful information for determining discharge.

There is no consensus on the definition of failure after treatment in patients with achalasia. The Eckardt score is used to define clinical outcomes. However, objective metrics are lacking. This study aimed to identify whether any high-resolution manometry (HRM) parameters may be useful in predicting a positive outcome after laparoscopic Heller-Dor (LHD).

Patients who underwent LHD between 2012 and 2022 were enrolled. The patients were divided according to the outcome: the success group (SG) and the failure group (FG). In addition to the common HRM parameters, we measured the difference between pre- and postoperative integrated relaxation pressures (∆-IRPs). A receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of each HRM parameter.

Of note, 336 patients (92.3%) were classified in the SG, and 28 patients (7.7%) were classified in the FG. No difference was found in terms of manometric types, symptom duration, and history of previous treatments. Preoperative lower esophageal sphincter (LES) pressure and IRP were higher in the SG than in the FG (41 vs 35 mm Hg [P =.03] and 33 vs 26 mm Hg [P =.002], respectively). The postoperative LES metrics were similar between the 2 groups, except for the ∆-IRP that was higher in the SG (23 mm Hg [IQR, 15-31]) than in the FG (14 mm Hg [IQR, 9-17]) (P =.0002). In the univariate analysis, age, LES preoperative pressure, IRP, and ∆-IRP were factors able to predict a positive clinical outcome. In the multivariate analysis, the ∆-IRP was the only parameter independently related to clinical success (odds ratio, 0.94; 5%-95% CI, 0.89-0.99). The ROC curve for the ∆-IRP showed an area under the curve of 0.71, with a threshold value set at 16.5 mm Hg (sensibility of 71% and specificity of 70%).

Our data showed that the ∆-IRP with a threshold of 16.5 mm Hg could represent a new objective tool for predicting the long-term positive outcome of LHD in patients with esophageal achalasia.

High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function.

Cross-sectional study.

Referral centre.

HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3).

2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001).

Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50 mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6 mmHg (> 26 mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6 mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

The aim of this prospective, controlled study was to assess the 5-year follow-up of laparoscopic Heller-Dor (LHD) in patients with esophago-gastric junction outflow obstruction (EGJOO), compared with achalasia patients (ACH). The management of EGJOO reflects the experience gained with esophageal achalasia, for which LHD has been proven to be an effective long-term treatment. Prospective long-term results of LHD in EGJOO patients are still lacking.

Patients with diagnosis of idiopathic EGJOO referred for dysphagia or food-regurgitation, treated with LHD, were enrolled and then followed prospectively for 5 years. During the follow-up, patients were evaluated with Eckardt score (ES), Barium-swallow X-ray, high-resolution manometry (HRM), 24-hour pH-monitoring and endoscopy. Primary outcome was therapeutic success (ES ≤ 3 or no additional treatment).

The study involved 150 patients: 25 in the EGJOO group and 125 in the ACH group. After 5 years, there was no significant difference in success rate: 90.5% in the EGJOO group, 87.5% in ACH stage I - pattern I, 91.6% in ACH stage I - pattern II and pattern III ( P = 0.94). The ES and all the HRM parameters were similar in all groups. Moreover, the screening endoscopy and the 24-hour pH-monitoring showed a similar postoperative acid exposure in all groups.

This is the first study based on prospective data to assess the long-term outcome of LHD in patients with EGJOO. After at least 5 years of follow-up, LHD has a comparable success rate in both EGJOO and achalasia patients and can be proposed as a safe and effective treatment for EGJOO patients.

While functional endoscopic evaluation of swallowing (FEES) is the most useful diagnostic test for the evaluation of dysphagia, it cannot evaluate the esophageal phase of swallowing. To evaluate if a modification for the FEES exam by swallowing an empty capsule and screening of the upper esophagus could be used for early detection of esophageal dysphagia. A prospective, single-center, pilot study. At the end of a standard FEES exam, the patients were asked to swallow an empty capsule. Fifteen seconds later, the endoscope was inserted into the upper esophagus. A pathological capsule test was defined when the capsule was seen in the esophagus. In such cases, the patient was advised to undergo a gastroscopy, MBS, or esophageal manometry, which were compared to the results of the capsule test. The capsule test was utilized in 109 patients. A pathological capsule test was found in 55 patients (57.8%). In 48 patients (87.3%), an isolated or combined esophageal dysphagia was seen. The accuracy value of the capsule test compared to gastroenterology tests was 83.3%, sensitivity 88.46%, specificity 75%, PPV 85%, and NPV 80%. A modification of the standard FEES exam by including an empty capsule swallow test with an upper esophagus examination may provide a useful screening tool for esophageal dysphagia.

Distal mean nocturnal baseline impedance (MNBI) measuring via pH-impedance may be valuable in diagnosing patients with suspected laryngopharyngeal reflux (LPR). However, its wide adoption is hindered by cost and invasiveness. This study investigates whether baseline impedance measured during high-resolution impedance manometry (HRIM-BI) can predict pathological MNBI.

A cross-sectional study in Taiwan included 74 subjects suspected of LPR, who underwent HRIM (MMS) and pH-impedance testing (Diversatek), after stopping proton pump inhibitors for more than 7 days. Subjects with grade C or D esophagitis or Barrett's esophagus were excluded. The cohort was divided into 2 groups: those with concomitant typical reflux symptoms (CTRS, n = 28) and those with isolated LPR symptoms (ILPRS, n = 46). HRIM-BI measurements focused on both distal and proximal esophagi. Pathological MNBI was identified as values below 2065 Ω, measured 3 cm above the lower esophageal sphincter.

In all subjects, distal HRIM-BI values correlated weakly with distal MNBI(r = 0.34-0.39, P < 0.005). However, in patients with ILPRS, distal HRIM-BI corelated moderately with distal MNBI(r = 0.43-0.48, P < 0.005). The areas under the receiver operating characteristic curve was 0.78 (P = 0.001) with a sensitivity of 0.83 and a specificity of 0.68. No correlation exists between distal HRIM-BI and distal MNBI in patients with CTRS, and between proximal HRIM-BI and proximal MNBI in both groups.

Distal HRIM-BI from HRIM may potentially predict pathological MNBI in patients with ILPRS, but not in those with CTRS. Future outcome studies linked to the metric are warranted.

Multiple rapid swallows (MRS) is a provocative test during high-resolution esophageal manometry (HRM) to evaluate contraction reserve (CR). This study aims to determine the prevalence of CR in patients with ineffective esophageal motility (IEM) and MRS performed in the upright position, and to assess the ideal number of MRS sequences.

We enrolled adult patients diagnosed with IEM according to the Chicago classification version 4.0 who underwent HRM with 3 MRS sequences. Presence of CR was identified as either: the distal contraction integral (DCI) of the post-MRS sequence exceeding the mean DCI of single swallows (ratio > 1) or the mean DCI of the 3 post-MRS sequences surpassing the mean DCI of single swallows. The occurrence of CR was compared following 1, 2, and 3 MRS sequences.

When assessing CR in 57 patients referenced to mean single supine swallow DCI, the pooled prevalence of CR following 1, 2, and 3 MRS sequences was 23/57 (40.4%), 31/57 (54.4%), and 33/57 (57.9%), respectively. More patients had CR after 2 MRS sequences compared to 1 (P < 0.001), but there was no significant difference in CR between 2 and 3 MRS sequences (P = 0.160). More patients had CR after 2 (P = 0.013) and 3 MRS sequences (P = 0.034) when CR was referenced to single upright compared to single supine swallows.

Among patients with IEM, 58.0% had CR after 3 upright MRS sequences and 2 were adequate to assess CR.

The endoscopic pressure study integrated system (EPSIS) measures intragastric pressure (IGP) during esophagogastroduodenoscopy. Previous research demonstrated that EPSIS correlates with the 24-h impedance-pH (MII-pH) test and shows lower maximum IGP (IGP-Max) and a flatter waveform gradient in gastroesophageal reflux disease (GERD) patients, attributed to lower esophageal sphincter dysfunction. Although endoscopic antireflux therapy (EARTh) is effective for GERD, the MII-pH monitoring, the gold standard for assessing treatment outcomes, requires hospitalization and can be a burden. EPSIS offers a noninvasive alternative for evaluating post-EARTh outcomes. This study aimed to assess EPSIS as an additional diagnostic tool in this context.

We conducted a retrospective analysis of GERD patients who underwent EARTh and were subsequently assessed using EPSIS within 6 months, from May 2018 to April 2024. Changes in IGP parameters, including IGP-Max and waveform gradient, were analyzed pre- and post-EARTh. Additionally, the study examined Hill's Classification following EARTh.

Out of 39 patients assessed with EPSIS before and after EARTh, the average age was 55 years (standard deviation [SD] 16.7), with 64.1% male. Postoperative IGP-Max increased from 15.2 mmHg to 18.0 mmHg (P = 0.004), and the pressure gradient improved from 0.16 mmHg/s to 0.28 mmHg/s (P < 0.001). Hill's Classification improved significantly from a mean of 2.2 (SD 0.7) to 1.1 (SD 0.3) (P < 0.001).

This study indicates that EPSIS is a reliable diagnostic tool for evaluating the effects of EARTh and holds potential as a supplementary tool for assessing GERD treatment outcomes.

Esophagogastric junction outflow obstruction (EGJOO) can be an achalasia variant caused by neuromuscular dysfunction of the lower esophageal sphincter (LES), or the manometric manifestation of mechanical processes that impair EGJ distensibility. Distinction among these conditions has important implications for treatment, but can be difficult. We hypothesized that response to botulinum toxin (BT) injection of the LES could be a diagnostic test for identifying achalasia-variant EGJOO likely to respond to LES muscle-directed invasive therapy. We reviewed our experience with symptomatic EGJOO patients who had BT injection of the LES. Data collected include demographics, esophageal body manometry findings, esophagram evidence of retention, and symptom response at 1-6 months after BT injection categorized as poor, partial, or good. Clinical response to any subsequent LES-directed invasive treatment (EsoFLIP dilation, pneumatic dilation, Heller myotomy, or POEM) also was recorded. Thirteen symptomatic EGJOO patients were included (mean age 55.9 ± 16.4 years; eight men, five women). Symptom response to BT injection was good in six (46%), partial in three (23%), and poor in three (23%); one was lost to follow-up. All five patients who received invasive treatment after partial or good response to BT had a partial or good response to invasive treatment. The one patient who had invasive treatment after a poor response to BT had a poor response to invasive treatment. These findings suggest that a good response to BT injection of the LES can identify an achalasia-variant form of EGJOO that will respond to LES muscle-directed invasive therapy.

While it is commonly known that patients with rheumatologic diseases can have esophageal dysfunction, this association is insufficiently understood. The aim is to determine the prevalence and characteristics of esophageal motility disorders in patients with rheumatic diseases. This is a single-center retrospective study of adults with rheumatologic disease who underwent high-resolution esophageal manometry (HREM). Those with and without a motility disorder (defined per Chicago classification CCv3.0 criteria, given the timing of the prior studies) were compared and multivariable logistic regression was used to determine odds of motility disorder by rheumatic disease. Of 289 patients, the mean age was 60.5 ± 13.8 years. Rheumatic diseases included Raynaud's (42%), rheumatoid arthritis (RA) (39%), Sjogren's (21%), systemic lupus erythematous (19%), systemic sclerosis (17%), and mixed connective tissue disease (13%). On HREM, 58% had an esophageal motility disorder: achalasia (5%), EGJ outflow obstruction (20%), jackhammer (8%), diffuse esophageal spasm (1%), ineffective esophageal motility (28%), and fragmented peristalsis (2%). Of note, 50% of the sample with a normal barium swallow had an esophageal dysmotility disorder on HREM. Those with psoriatic arthritis were less likely to have esophageal dysmotility (73% vs. 27%; P = 0.04). There was decreased odds of esophageal hypocontractility in those with RA (OR [95%CI]: 0.27 [0.12-0.58]) and increased odds (OR [95%CI]: 3.13 [1.16-8.41]) of esophageal hypocontractility among those with scleroderma. Esophageal motor disorders were found in more than half of patients with rheumatologic diseases who underwent HREM. HREM should be considered in patients with rheumatic conditions presenting with esophageal symptoms.

Eosinophilic esophagitis (EoE) presents with various esophageal motility disorders, and some cases of hypercontractile esophagus (HE) are associated with eosinophilic esophageal myositis (EoEM). This study aimed to compare the clinical characteristics of patients with EoE and EoEM according to their esophageal motility.

The 28 patients with EoE and 2 patients with EoEM were divided into three groups based on esophageal motility: normal motility group, hypomotility group, and spastic contraction group. The clinical characteristics of the three groups were retrospectively compared.

Among the 28 patients with EoE, there were 15 with normal esophageal motility, 9 with hypomotility (2 with absent contractility, 7 with ineffective esophageal motility), and 4 with spastic contractions (1 with type III achalasia, 1 with HE, 2 with unclassifiable multipeak contractions). The two patients with EoEM had HE. Most patients in the normal and hypomotility groups had typical endoscopic findings of EoE, whereas these typical findings were less common in the spastic contraction group (P < 0.001). Four of the five patients with esophageal stricture were in the hypomotility group (P = 0.036). The therapy method significantly differed between the three groups: the normal group had more patients that responded to a proton pump inhibitor or potassium-competitive acid blocker, the hypomotility group had more patients that responded to steroids, and the spastic contraction group contained two patients treated with per-oral endoscopic myotomy (P = 0.021).

The endoscopic findings and therapy methods differ between patients with EoE and EoEM based on the esophageal motility.

This study investigates multiple rapid swallows during high-resolution esophageal manometry (HREM) as an indicator of esophageal dysmotility following bariatric surgery. Gastrointestinal complications, including esophageal dysfunction, are common after bariatric surgery, and predictive markers are lacking.

Retrospective analysis of adult patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2013 and 2023 and were subsequently evaluated by HREM. Contractile reserve (CR) and breakthrough contractions were assessed during MRS and HREM studies assessed by the Chicago Classification version 4.0.

Breakthrough contractions were found in 52.2% of patients undergoing HREM during multiple rapid swallows (MRS), including 70% of patients classified as normal manometry. Presence of breakthrough contractions correlated with greater DCI (1039 vs. 446 mmhg-s-cm, p = 0.05), and was more common after SG compared to RYGB (58.3% vs. 41.7%, p = 0.089) and in proton pump inhibitor users (100% vs. 72.7%, p = 0.093). Contractile reserve was observed in 56.5% of patients, similar to non-bariatric cohorts.

Breakthrough contractions are frequent in post-bariatric patients, even with normal manometry, suggesting early esophageal dysfunction. Sleeve gastrectomy patients showed a higher trend of these contractions, potentially due to increased intragastric pressure. Further studies are needed to understand long-term implications.