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.
Background When multiple swallows are rapidly administered, esophageal peristalsis is inhibited, and pronounced lower esophageal sphincter relaxation ensues. After the last swallow of the series, a robust contraction sequence results. The authors hypothesize that multiple rapid swallows (MRS) may have value in predicting esophageal transit symptoms in patients undergoing laparoscopic antireflux surgery (LARS). Methods Records of patients undergoing esophageal high-resolution manometry (HRM) before LARS were evaluated. The evaluation of MRS included adequate inhibitory response during swallows and the contraction pattern after MRS. Dysphagia was scored based on a product of symptom frequency and severity using 5-point Likert scales. A composite dysphagia score comprised the sum of scores for solid and liquid dysphagia, and a score of 4 or higher was considered clinically significant. The normal and abnormal MRS responses of patients with preoperative, early, and late postoperative dysphagia were compared with those of patients with no dysphagia. Results In this study, 63 patients (mean age, 60.3 ± 1.7 years, 48 women) undergoing HRM before LARS successfully performed MRS (median, 5 swallows; longest interval between swallows, 3.2 ± 0.1 s). After MRS, 14 patients (22.2 %) had an intact peristaltic sequence. Complete failure of peristalsis was seen in 21 (33.3 %), and incomplete esophageal inhibition in 25 (39.7 %) of the remaining patients. When stratified by presence or absence of dysphagia, 58.3 % of the subjects without dysphagia had a normal MRS response, whereas 83.3 % had formation of peristaltic segments after MRS. In contrast, only 14 % of the subjects with dysphagia had a normal MRS response (p ≤ 0.003 vs. the subjects with no dysphagia). Abnormal MRS responses were more prevalent in the patients with any preoperative and late postoperative dysphagia (p = 0.04 across groups) and in those with clinically significant dysphagia (p = 0.08 across groups). Conclusions High-resolution manometry with MRS helps to predict dysphagia in subjects undergoing preoperative esophageal function testing before LARS.
SUMMARY Background Both simple proportions and statistical tests are utilised for symptom-reflux association. We systematically compared three such tests in a clinical setting. Aim To compare the three commonly used symptom reflux association tests in a large cohort of patients undergoing ambulatory pH monitoring for the evaluation of oesophageal symptoms. Methods Ambulatory pH data from 772 symptomatic subjects (49.1 ± 0.5 years; 479 F) tested off therapy were assessed for acid exposure time (AET, elevated when pH <4 for ≥4%), symptom index (SI, ≥50% when positive), and symptom association probability (SAP) and Ghillebert probability estimate (GPE, P < 0.05 when positive). Test concordance and discordance were individually assessed; discordance between statistical tests was minor if one had P < 0.1 while the other was positive. Logistic regression determined independent predictors of test discordance. Results The SAP, GPE and SI were positive in 42.7%, 39.3% and 33.9% respectively. GPE performed extremely well compared to SAP (sensitivity 0.95, specificity 0.91), with major discordance in only 2.8%. Positive concordance was significantly higher when AET was abnormal. GPE underestimated symptom association compared to SAP, whereas SAP was subject to symptom over-counting in 33.3% of discordant cases. GPE-SAP discordance was associated with higher AET (7.5% vs. 5.1%) and more symptoms (19.3 vs. 10.7, P > 0.001 for each comparison with concordant tests); both remained significant on logistic regression analysis (P ≥ 0.003). SI was discordant with SAP when symptoms were extremely frequent (median 19, IQR 10–32) or limited (median 1, IQR 1–2), and concordant when median 6 symptoms (IQR 3–12) were recorded. Conclusions The GPE can be used interchangeably with SAP in symptom reflux association. SI has uncertain value with very high and very low symptom counts.
Evaluation of smooth muscle contraction segments adds value to HRM analysis. Specifically, fragmented smooth muscle contraction segments may be a marker of esophageal hypomotility.
Background High-resolution manometry (HRM) utilizes software tools to diagnose esophageal motor disorders. Performance of these software metrics could be affected by averaging and by software characteristics of different manufacturers. Methods HRM studies on 86 patients referred for antireflux surgery (61.6±1.4 yr, 70% F) and 20 healthy controls (27.9±0.7 yr, 45% F) were first subject to standard analysis (Medtronic, Duluth, GA). Coordinates for each of 10 test swallows were exported and averaged to generate a composite swallow. The swallows and averaged composites were imported as ASCII file format into Manoview (Medtronic, Duluth, GA) and Medical Measurement Systems database reporter (MMS, Dover, NH), and analyses repeated. Comparisons were made between standard and composite swallow interpretations. Results Correlation between the two systems was high for mean distal contractile integral (DCI, r2≥0.9) but lower for integrated relaxation pressure (IRP, r2=0.7). Excluding achalasia, six patients with outflow obstruction (mean IRP 23.2±2.1 with 10-swallow average) were identified by both systems. An additional 9 patients (10.5%) were identified as outflow obstruction (15 mmHg threshold) with MMS 10-swallow and 4 with MMS composite swallow evaluation; only one was confirmed. IEM was diagnosed by 10 swallow evaluation in 19 (22.1%) with Manoview, and 20 (23.3%) with MMS. On Manoview composite, 17 had DCI<450 mmHg.cm.s, and on MMS composite, 21, (p≥0.85 for each comparison) but these did not impact diagnostic conclusions. Conclusions Comparison of 10 swallow and composite swallows demonstrate variability of software metrics between manometry systems. Our data supports use of manufacturer specific software metrics on 10 swallow sequences.
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