Background Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM. Methods Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM. Key Results Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08). Conclusions & Inferences Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS.

Background Esophagogastric junction contractile integral (EGJ-CI) assesses EGJ barrier function on esophageal high resolution manometry (HRM). We assessed EGJ-CI values in achalasia and gastroesophageal reflux disease (GERD) to determine if postoperative EGJ-CI changes reflected surgical intervention. Methods 21 achalasia patients (42.8±3.2 yrs, 62% F) with HRM before and after Heller myotomy (HM) and 68 GERD patients (53.9±1.8 yrs, 66% F) undergoing anti-reflux surgery (ARS) were compared to 21 healthy controls (27.6±0.6 yrs, 52% F). EGJ-CI (mmHg.cm) was calculated using the distal contractile integral (DCI) measurement across the EGJ, measured above the gastric baseline and corrected for respiration. Pre- and post-surgical EGJ-CI and conventional lower esophageal sphincter pressure (LESP) metrics were compared within and between these groups using non-parametric tests. Correlation between EGJ-CI and conventional LESP metrics was assessed. Results Baseline EGJ-CI was higher in achalasia compared to GERD (p<0.001) or controls (p=0.03). EGJ-CI declined by 59.2% after HM in achalasia (p=0.001), and increased by 26.3% after ARS in GERD (p=0.005). End-expiratory and basal LESP decreased by 74.5% and 64.5% with HM, but increased by only 17.8% and 4.3% with ARS. Differences were noted between Dor vs. Toupet fundoplication in achalasia (p=0.007), and partial vs. complete ARS in GERD (p=0.03). EGJ-CI correlated modestly with both end-expiratory and basal LESP (Pearson’s r of 0.8 for all), but was less robust in GERD (0.7). Conclusions EGJ-CI has clinical utility in assessing EGJ barrier function at baseline and after surgical intervention to the EGJ, and could complement conventional EGJ metrics.

No abstract

Background Two smooth muscle contraction segments (S2, S3) on esophageal high-resolution manometry (HRM) demonstrate varying contraction vigor in symptomatic patients. Significance of isolated exaggerated smooth muscle contraction remains unclear. Methods High-resolution manometry studies were reviewed in 272 consecutive patients (56.4 ± 0.8 years, 62% F) and compared to 21 healthy controls (27.6 ± 0.6 years, 52% F), using HRM tools (distal contractile integral, DCI; distal latency, DL; integrated relaxation pressure, IRP), Chicago Classification (CC) and multiple rapid swallows (MRS). Segments were designated merged when the trough between S2 and S3 was ≥150 mmHg, and exaggerated S3 when peak S3 amplitude was ≥150 mmHg without merging with S2. Presenting symptoms and global symptom severity (on 100 mm visual analog scale) were recorded. Prevalence of merged and exaggerated segments was determined, and characteristics compared to symptomatic patients with normal HRM, and to healthy controls. Key Results Merged segments were identified in 5.6%, and exaggerated S3 in another 12.5%, but only 17–50% had a CC diagnosis; one healthy control had merged segments. DCI with wet swallows was similar in cohorts with merged and exaggerated segments (p = 0.7), significantly higher than symptomatic patients with normal HRM and healthy controls (p ≤ 0.003 for each comparison). Incomplete inhibition and prominent DCI augmentation on MRS (p ≤ 0.01), and presenting symptoms (chest pain and dysphagia, p = 0.04) characterized exaggerated segments, but not demographics or symptom burden. Conclusions & Inferences Merged esophageal smooth muscle segments and exaggerated S3 may represent hypermotility phenomena from abnormal inhibition and/or excitation, and are not uniformly identified by the CC algorithm.

Achalasia is an esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) with lack of peristaltic esophageal body contractions. 1 Loss of inhibitory ganglion cells in the myenteric plexus results in an imbalance between excitatory and inhibitory neurotransmitters, resulting in net increased basal LES tone, and abnormal LES relaxation. 1 The